Delegate and Advisor Registration Form
Delegate Information
School Name:
First Name: Last Name:
Preferred Name for Name Tag:
Gender: Male Female Transgender
Date of Birth (mm/dd/yyyy): / /       E-mail Address:

Delegate Status:
First Time Delegate
Delegate
NRHH Member
President
PCC
NCC
NCC In Training
Advisor
RBD
MACURH 2010 Bid Team
Guest
T-shirt Size: XS S M L XL XXL XXXL

Dining:
Vegetarian
Vegan
Kosher
Non-Dairy
Other - Specify (peanuts, MSG, chocolate, etc):
No Restriction

Housing:
Are there any special housing needs? (wheelchair accessibility, ADA, etc)
Yes No
If yes, please specify:

Additional Housing:
Check below if you will need additional housing on the following nights. Additional housing will be charged at the hotel's nightly rate.
Thursday, October 22nd Monday, October 25th

Emergency Contact Information:
First Name:
Last Name:
Relationship:
Primary Phone Number: Secondary Phone Number:
E-mail Address:
On-site/At Conference Contact Name:
On-site/At Conference Phone Number:

Insurance Information:
Name of Carrier:
Policy Number: